Microvascular decompression is a first-line neurosurgical approach for classical trigeminal neuralgia with neurovascular conflict, but can show clinical relapse despite proper decompression. Second-line destructive techniques like radiofrequency thermocoagulation have become reluctantly used due to their potential for irreversible side effects. Subcutaneous peripheral nerve field stimulation (sPNFS) is a minimally invasive neuromodulatory technique which has been shown to be effective for chronic localised pain conditions.
The most frequently used surgical management of trigeminal neuralgia is Microvascular decompression (MVD), followed closely by stereotactic radiosurgery (SRS). Percutaneous stereotactic rhizotomy (PSR) , despite being the most cost-effective, is by far the least utilized treatment modality 1).
Although microvascular decompression (MVD) is the most effective long-term operative treatment for TN, its use in older patient populations has been debated due to its invasive nature.
It has proven to be the most successful and durable surgical approach for trigeminal neuralgia (TN).
However, not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.
It does not achieve 100 % cure rate. Re-exploration of the posterior fossa may carry increased risk over first-time MVD and is not always successful, so other treatments are needed.
Subjects underwent MVD for TN at the Department of Neurosurgery, Massachusetts General Hospital, Boston, between 1/1/2004 and 12/31/2013, had typical TN, and demonstrated neurovascular compression on preoperative imaging. We performed a retrospective case series study by reviewing the electronic medical records and performing phone interviews to determine long-term outcomes. We divided patients into 2 groups for analysis, under 60 and 60 yr of age and older.
One hundred twenty-four subjects were included in the study, 82 under 60, and 42 60 yr of age and older. The average length of follow-up was 42.4 mo. Patients in the older age group had average pain score of 1.57 at most recent follow-up, while for the younger age group it was 2.18 (P = .0084). Multiple regression analysis found that older age, male gender, and preoperative medication responsiveness were significantly correlated with lower long-term pain scores, while V2 dermatome involvement was correlated with higher long-term pain scores.
Patients 60 yr of age and older have significantly better long-term pain outcomes following MVD than younger patients 2).
Zhao et al. summarize 5-year experience of MVD for primary TN due to venous compression alone. Thirty-four patients with primary TN caused solely by veins underwent MVD. The presenting symptoms, key operative notes, surgical outcomes together with complications were reviewed. Of all the 34 patients, 19 (55.9%) patients occurred as typical TN. The V2 division was the most commonly affected area. Most of the venous conflicts were grade III (20/34, 58.8%). Deep superior petrosal venous system was the most frequent offending vessel (21/34, 61.8%). The venous conflicts were located at the trigeminal root entry zone in 10 (29.4%) patients, the mid cisternal zone in 18 (52.9%) patients, and the porus of Meckel's cave in 11 (32.4%) patients. At the last follow-up, excellent outcome was obtained in 26 (76.5%) patients, 7 (20.6%) patients got good outcome, fair outcome was achieved in 7 (20.6%) patients, and 1 patient unimproved (2.9%). Cerebrospinal fluid leakage was the most common complication (5.9%). In conclusion, MVD is a safe and effective surgical option for TN due to venous compression alone. It is noteworthy to explore the entire nerve and to protect veins as much as possible 3).
Yang et al. investigate the characteristics of superior petrosal vein (SPV) and its influence on the surgical field in microvascular decompression for trigeminal neuralgia (TN), and analyze the effect of the surgical treatment of SPV on the surgical approach, indication and prognosis.
The clinical data of 280 patients with trigeminal neuralgia between Jan. 2013 and Jun. 2016 were collected, including the trunks and the branches of SPV, intraoperative electrocoagulation status, the surgery outcome and complications.
The petrosal vein during the operation was fully preserved in 152 cases (54.29%). The SPV were completely sectioned in 25 cases (8.92%), while some branches of SPV were sectioned in 103 cases (36.79%).
They found that SPV have 1 to 3 trunks, accounted for 67 cases (23.90%), 168 cases (60%), and 45 cases (16.10%), while the SPV with 1 to 4 branches accounted for 17 cases (6.07%), 112 cases (40%), 136 cases (48.57%), and 15 cases (5.36%). The SPV was identified as offending vessel in 17 cases (6.07%).
One patient with cutoff SPV trunk encountered cerebellar infarction and recovered completely at 2 weeks after MVD by using intravenous medication.
MVD is the recommended treatment method for PTN, mostly SPV is unnecessary to be sectioned completely and small branches of SPV could be sacrificed. Very few patients may develop cerebellar infarction or hematoma 4).
Clinical characteristics, intraoperative findings, and postoperative curative effects were analyzed in 72 patients with trigeminal neuralgia who were treated by microvascular decompression. The patients were divided into arterial and venous compression groups based on intraoperative findings. Surgical curative effects included immediate relief, delayed relief, obvious reduction, and invalid result. Among the 40 patients in the arterial compression group, 32 had immediate pain relief of pain (80.0%), 5 cases had delayed relief (12.5%), and 3 cases had an obvious reduction (7.5%). In the venous compression group, 12 patients had immediate relief of pain (37.5%), 13 cases had delayed relief (40.6%), and 7 cases had an obvious reduction (21.9%). During 2-year follow-up period, 6 patients in the arterial compression group experienced recurrence of trigeminal neuralgia, but there were no recurrences in the venous compression group. Simple artery compression was followed by early relief of trigeminal neuralgia more often than simple venous compression. However, the trigeminal neuralgia recurrence rate was higher in the artery compression group than in the venous compression group 5).
von Eckardstein et al., focused on whether ICG angiography is helpful in determining the site of conflict, particularly when not directly visible via the microscope, and whether fluorescence is strong enough to shine through the nerve obliterating the direct view of the compressing vessel.
In four patients, the site of conflict was immediately apparent after opening the cerebellopontine cistern, and ICG angiography did not provide the neurosurgeon with additional information. In another two patients, imaging quality and fluorescence were too poor. Of the remaining 11 patients with a hidden site of nerve-vessel conflict, ICG angiography was found to be helpful in anticipating the site of compression and the course of the artery in 7 patients, particularly in regard to the so-called shining-through effect through fiber bundles of the thinned nerve. Of all the patients, 88% reported at least improvement or cessation of their symptoms, including all of the patients with a shine-through effect.
ICG angiography could be a helpful adjunct in decompressing the trigeminal nerve and can guide the surgeon to the nerve-vessel conflict. Intensity of the fluorescence is powerful enough to shine through thinned and splayed trigeminal nerve fiber bundles 6).
A retrospective review of patient records from 1998 to 2015 identified a total of 942 patients with TN and 500 patients who underwent MVD. After excluding several cases, 306 patients underwent MVD as their first surgical intervention and 175 patients underwent subsequent MVD. Demographics and clinicopathological data and outcomes were obtained for analysis.
In patients who underwent subsequent MVD, surgical intervention was performed at an older age (55.22 vs 49.98 years old, p < 0.0001) and the duration of symptoms was greater (7.22 vs 4.45 years, p < 0.0001) than for patients in whom MVD was their first surgical intervention. Patients who underwent initial MVD had improved pain relief and no improvement in pain rates compared with those who had subsequent MVD (95.8% and 4.2% vs 90.3% and 9.7%, respectively, p = 0.0041). Patients who underwent initial MVD had significantly lower rates of facial numbness in the pre- and postoperative periods compared with patients who underwent subsequent MVD (p < 0.0001). The number of complications in both groups was similar (p = 0.4572).
The results demonstrate that patients who underwent other procedures prior to MVD had less pain relief and a higher incidence of facial numbness despite rates of complications similar to patients who underwent MVD as their first surgical intervention 7).
A retrospective analysis of clinical data was performed in 99 patients who underwent MVD from May 2012 to June 2015. The outcome data from 27 MVD operations for 27 patients aged 70-80 years (mean 74.6 years) were compared with 72 MVD operations with 72 patients aged 25-69 years (mean 55.7 years). Preoperative comorbidities were recorded and postoperative worsening comorbidities and non-neurological complications were evaluated at discharge. Efficacy of the surgery and neurological complications were evaluated in July 2015.
No decrease in activity of daily living was found in any patient. Complete pain relief without medication was achieved in 77.8% and partial pain relief in 14.8% in the elderly group, and 83.3% and 9.7%, respectively, in the non-elderly group (p=0.750). Permanent neurological complication was not observed in the elderly group, whereas Vth nerve and VIIIth nerve complications were observed in the non-elderly group. Rates of preoperative multiple comorbidities and of cardiovascular comorbidity were significantly higher in the elderly group (p<0.01). Worsening comorbidity and new pathology at discharge were mainly hypertension in both groups, but glaucoma attack and asthma attack were observed in the elderly group. All pathologies were successfully managed.
MVD for elderly patients with TN can be achieved safely with careful perioperative management. Information of comorbidity should be shared with all staff involved in the treatment, who should work as a team to avoid worsening comorbidity. The possibility of unpredictable events in the elderly patients should always be considered 8).
Since 2004, there were a total of 51 patients with TIC and 12 with HS with available MRI scans. All patients underwent preoperative MRI to rule out non-surgical etiologies for facial pain and facial spasm, and confirm vascular compression. Follow-up after surgery was 13±22 months for the patients with TIC and 33±27 months for the patients with HS.
There were 45 responders to MVD in the TIC cohort (88%), with a Visual analog scale (VAS) of 1±3. All patients with HS responded to MVD between 25 and 100%, with a mean of 75±22%. Wound complications occurred in 10% of patients with MVD for TIC, and 1 patient reported hearing loss after MVD for HS, documented by audiogram. The congruence rate between the preoperative MRI and operative findings of vascular compression was 84% in TIC and 75% in HS.
MVD is an effective and safe modality of treatment for TIC and HS. In addition to ruling out structural lesions, MRI can offer additional information by highlighting vascular loops associated with compressions. On conventional scans as obtained here, the resolution of MRI was congruent with operative findings in 84% in TIC and 75% in HS. This review emphasizes that the decision to undertake MVD in TIC or HS should be based on clinical diagnosis and not visualization of a compressing vessel by MRI. Conversely, the presence of a compressing vessel by MRI demands perseverance by the surgeon until the nerve is decompressed 9).
The trigeminal nerve was sectioned into 5 zones. Zone 1, 2, 3, 4 was located at the rostral, caudal, ventral, and dorsal part of the nerve root entry zone (REZ) respectively, and zone 5 was located at the distal of the nerve root. This study contained 86 patients with trigeminal neuralgia underwent microvascular decompression. Every zone was exposed through preoperative imaging. During the operation, offending vessels were explored from zone 1 to zone 5, and different decompression techniques were used for different types of vessels.
Through zone exploration, the sensitivity of preoperative imaging was 96.5% and specificity was 100%. Location of the neurovascular conflict was in the zone 1 in 53.5% of the patients, zone 2 in 32.6%, zone 3 in 45.3%, zone 4 in 29.1%, and zone 5 in 34.9%. In total, 2 zones were both involved in 59.3%, and 3 zones were involved in 18.6%. All offending arteries were moved away and interposed with Teflon sponge. Offending veins of 11 patients were too small to interpose, and coagulated and cut was adopted. The other offending veins were interposed with wet gelatin and Teflon sponge, respectively 10).
Lee et al. performed a retrospective review of cases of TN Type 1 (TN1) or Type 2 (TN2) involving patients 18 years or older who underwent evaluation (and surgery when indicated) at Oregon Health & Science University between July 2006 and February 2013. Surgical and imaging findings were correlated.
The review identified a total of 257 patients with TN (219 with TN1 and 38 with TN2) who underwent high-resolution MRI and MR angiography with 3D reconstruction of combined images using OsiriX. Imaging data revealed that the occurrence of TN1 and TN2 without NVC was 28.8% and 18.4%, respectively. A subgroup of 184 patients underwent surgical exploration. Imaging findings were highly correlated with surgical findings, with a sensitivity of 96% for TN1 and TN2 and a specificity of 90% for TN1 and 66% for TN2. Conclusions Magnetic resonance imaging detects NVC with a high degree of sensitivity. However, despite a diagnosis of TN1 or TN2, a significant number of patients have no NVC. Trigeminal neuralgia clearly occurs and recurs in the absence of NVC 11).
A study comprises 42 cases of trigeminal neuralgia that underwent operation with endoscopic-assisted microvascular decompression between October 1992 and October 1998. This study was performed in the Ear, Nose, and Throat Department, Nord Hospital, in Marseille, France. The decompression was performed by means of a minimally invasive retrosigmoid approach without a cerebellar retractor. The cerebellopontine angle was then explored by a 30-degree endoscope that gives a panoramic view of this space, with clear visualization of the trigeminal nerve from the pons to Meckel's cave, allowing for the identification of the precise location of the site of the conflict. Microvascular decompression was performed under the microscope by separating the offending vessel from the trigeminal nerve; separation was maintained by the insertion of a piece of Teflon.
The site of conflict was detected at the root entry zone of the nerve in 35 patients (83.3%) and at Meckel's cave in 7 patients (16.7%). In 32 cases (76.2%), the type of contact between the vessel and the nerve was of the simple type (1 vessel coming in contact with the nerve in a single point); in 6 cases (14.3%), it was a multiple type (2 vessels touching the nerve in the same point); and in 4 cases (9.5%), it was a nutcracker type (2 vessels compressing the nerve between them). After at least 1-year follow-up and a single operation (cases that required a second operation for revision were considered failures), a successful result was obtained in 31 cases (73.8%), and an improvement was obtained in 4 cases (9.5%). The operation was a failure or early recurrence occurred in 7 cases (16.7%). Postoperative complications were rare. A cerebrospinal fluid leak occurred in only 1 case (2.4%) and was subsequently treated with lumbar puncture and a compressive bandage.
The minimally invasive retrosigmoid endoscopic-assisted microvascular decompression is an acceptable treatment of primary trigeminal neuralgia. Endoscopy provides a unique way to explore the cerebellopontine angle and to identify the exact location of the neurovascular conflict 12).